Worksheet D-4 Parts III & IV

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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

MEDICAL UNIVERSITY OF SOUTH CAROLINA - CHARLESTON, SC
Cost report status - As Submitted
[Record Code 741780 - 2010]
This is a prior filing for this period.

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COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES FOR A TRANSPLANT HOSPITAL WITH A MEDICARE-CERTIFIED TRANSPLANT PROGRAM Provider CCN: 420004
PERIOD:
FROM 07/01/2021
TO 06/30/2022
 WORKSHEET D-4, PARTS III & IV
- Select other programs and provider types available
PART III - SUMMARY OF COSTS AND CHARGES
  Cost Charges  
Part A Part B Part A Part B
1 2 3 4
56 Routine and Ancillary from Part I ###   ###   56
57 Interns and Residents (inpatient)     57
58 Interns and Residents (outpatient)     58
59 Direct Organ Acquisition (see instructions) ###   ###   59
60 Cost of physicians' services in a teaching hospital (see instructions)     60
61 Total (see instructions) ###   ###   61
 
    Usable Organs      
1 2 3 4
62 Total Usable Organs (see instructions)   ###     62
63 Medicare Usable Organs (see instructions)   ###     63
64 Ratio of Medicare Usable Organs to Total Usable Organs (line 63 ÷ line 62)   ###     64
 
  Cost Charges  
Part A Part B Part A Part B
1 2 3 4
65 Medicare Cost and Charges (see instructions) ###   ###   65
66 Revenue for Organs Sold (see instructions) ###     66
66.01 Partial primary payor amounts applicable to organ acquisition     66.01
66.02 Partial primary payor amounts applicable to transplants (informational only)     66.02
67 Subtotal (see instructions) ###   ###   67
68 Organs Furnished Part B 68
69 Net Organ Acquisition Cost and Charges (see instructions) ### ### 69
PART IV - STATISTICS
  Living Related Cadaveric Revenue  
1 2 3
70 Organs Excised in Provider (1) ###   70
71 Organs Purchased from Other Transplant Hospitals (2)   71
72 Organs Purchased from Non-Transplant Hospitals   72
73 Organs Purchased from OPOs (see instructions) ###   73
74 Total (sum of lines 70 thru 73) ###   74
75 Organs Transplanted ### 75
75.01 Organs transplanted into Medicare beneficiaries   75.01
75.02 Kidneys transplanted into MA beneficiaries   75.02
75.03 Organs transplanted, Medicare secondary payer 75.03
75.04 Organs transplanted, Other (see instructions)   75.04
76 Organs Sold to Other Hospitals 76
77 Organs Sold to OPOs ### ### 77
78 Organs Sold to Transplant Hospitals 78
79 Organs sold to MRTC without an agreement or VA hospitals 79
79.01 Kidneys sold to MRTC with an agreement 79.01
80 Organs Sold Outside the U.S. 80
81 Organs Sent Outside the U.S. (no revenue received)   81
82 Organs Used for Research 82
83 Unusable/Discarded Organs (see instructions)   83
84 Total (see instructions) ### 84
(1) Organs procured outside your center by a procurement team from your center are not included in the count.
(2) Organs procured outside your center by a procurement team from your center are included in the count.
FORM CMS-2552-10  (03-2023)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, §4028.3)
03-23   Rev. 19